17 Endometrioma without surgery and IVFTreatment with a GnRH agonist for 3‐6 months before IVF or ICSI should be considered in women with endometriosis as it increases the odds of clinical pregnancy fourfold.However the authors of the Cochrane review stressed that the recommendation is based on only one properly randomised study and called for further research, particularly on the mechanism of actionSallam et al., 2006

18 Endometrioma and surgeryLaparoscopic ovarian cystectomy in patients with unilateral endometriomas between 3 and 6 cm in diameter before IVF/ICSI can decrease ovarian response without improving cycle outcome.In the prospective randomized trial 49 patients underwent conservative ovarian surgery before the ICSI cycle and 50 patients underwent the ICSI cycle directly.Ovarian stimulation parameters for those who underwent ovarian endometrioma cystectomy were significantly reduced and fewer mature oocytes were retrieved in the cystectomy group.No difference in implantation and clinical pregnancy rates were detectedDemirol et al.,2006

19 Endometrioma and surgeryStudies evaluating the response to ovarian stimulation in patients previously operated for endometriomas have led to controversial results in terms of ovarian response and cycle outcome.In patients with unilateral disease a significantly reduced number of follicles in the operated ovary compared to the intact side were reported in several but not all studies. The authors of one systematic review conclude that overall evidence suggests that surgery does not benefit asymptomatic women preparing to undergo IVF‐ICSI who are found to have an endometrioma Somigliana et al.,2006

20 Endometrioma and surgeryThe observation of an impaired ovarian response in women with endometriomas does not clarify whether the damage is consequent to surgery or antecedent to the intervention.An observational study in women with unilateral endometriomas who did not undergo previous ovarian surgery showed a significant mean reduction in follicles in the affected ovaries, suggesting that the presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotrophinsSomigliana et al., 2006

21 Endometrioma and surgeryThe other meta analysis indicates that ovarian endometrioma have adverse effects on follicle number and oocytes retrieved but not on embryo quality or pregnancy outcomes.Surgery may decrease the number of retrieved oocytes, but the overall fertility outcome is not affected Gupta et al., 2006

22 In SummaryLaparoscopic ovarian cystectomy can be considered if an ovarian endometrioma >4 cm in diameter is present toconfirm the diagnosis histologically;reduce the risk of infection;improve access to follicles andpossibly increase spontan pregnancy rate.

32 Effects of Myomas on Fertility in patients undergoing assisted reproductionThe aim is to evaluate the current data to understand the impact of intramural leimyomata on pregnancy outcome in ART without cavitary distortion.Benecke et all 2005

33 Patients Selection Pregnancy date on IVFIntramural myomas with no cavitary distortionControl group with no myomata150 Articles were reviewed Benecke et all 2005

35 If myoma ≤4cm, IVF-ICSI outcomes is similar to those without myomasImpact of subserosal and intramural myomas(without endometrial cavity distortion) on the outcome of in IVF-ICSI (245 Patients)If myoma ≤4cm, IVF-ICSI outcomes is similar to those without myomasHowever they receomended surgery, if myoma ≥4cmOliveira et all 2004

36 Which method should be used to remove intramural myomata?Laparoscopic surgeryLaparotomic microsurgeryRobotic Laparoscopic Surgery

38 CONCLUSION of MYOMASIntramural myomata without intracavitary involvement have an impact on pregnancy outcome in ART and surgical removal must be considered especially in patients with previous failed ART cycles.Intramural myomata with intracavitary involvement has to be removed.Myomectomy can be performed easily by laparoscopic surgery in the hand of the well trained surgeons.We await in anticipation a prospective randomized controlled trails that assess the effect of the size and position of intramural myoma on fertility in ART

65 HYSTEROSCOPY, as a routine examinations, should be performed before the first IVF – ET cycle in all patientsTHEY FOUND a statistically significant difference in pregnancy rate between women who performed hysteroscopy before IVF – ET and who did not performed it.DOLDI 2005, HINCKLEY 2003

71 The real endometrial surface and volume occupied by a submucous myoma The destiny of myomas: should we treat small (<1.5 cm) submucous myomas in women of reproductive age?The real endometrial surface and volume occupied by a submucous myomathe high potential of a small myoma to grow during the reproductive ageits negative impact on reproductionmalignancy potentialA "wait-and-see" approach is no longer acceptable in women of reproductive age with small submucous myomas, especially if the lesion could be easily and safely removed in an outpatient setting with minimal patient's discomfort.Bettocchi S et al., Fertil Steril, 2008

74 Endometrial polyps may be associated with increased miscarriage rates The frequencies of unrecognized uterine pathology revealed by hysteroscopy are 18-50% and 40-43% in patients undergoing IVF with or without RlF, respectivelyEndometrial polyps may be associated with increased miscarriage ratesImplantation rates are decreased in patients with submucous or intramural fibroids with distorted uterine cavityThere is controversy on the impact of uterine septum less than 1 cm length on pregnancy outcome in IVF cyclespregnancy rates appear to be increased when hysteroscopy is performed after failed IVF cyclesBozdağ G et al., Reprod Biomed Online, 2008

75 44 septate uterus and otherwise unexplained infertility (group A), and 132 women with unexplained infertility (group B)Pregnancy rate (38.6% vs. 20.4%) and live birth rate (34.1% and 18.9%) were significantly higher in group A than in group BHysteroscopic resection of the septum improves fecundity of women with septate uterus and otherwise unexplained infertilityMollo A et al., Fertil Steril,2008

78 T-Shaped UterusIt should be noted that classic small T-shaped uterine cavity also has been found in women who were not exposed to DES in utero- congenital mullerian malformation- uterine infection- uterine instrumentationRennell CL. AJR Am J Roentgenol 1979

89 Hysteroscopic metroplasty in DES-exposed and hypoplastic uterus: a report on 24 casesIt is an effective procedure in the case of recurrent abortion (88% 12.5%)It improves the rate of term delivery(3% 87.5%)Garbin et al. Human Reproduction 1998

90 ConclusionHysteroscopic metroplasty for T-Y shaped uterus seems to be an operation that improves the rate of live birth rate with a history of- primary infertility- recurrent abortion- preterm deliveryin order to evaluate the efficiency of this technique, randomised trials should be undertaken with larger series